Leeds Teaching Hospitals Trust Guidelines for Chest Drain Insertion

• Training
• Decision to insert a drain
• Pre-insertion considerations
• Site and technique of drain insertion
• Management of drainage system

Training

• All personnel inserting chest drains should be adequately trained and have been deemed competent at insertion, or be directly and appropriately supervised by an individual who is competent.

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Decision to insert a drain

• Prior to inserting a chest drain, the clinical team should question: Is a chest drain necessary?  Am I competent to do this? Does it have to be done as an emergency/out of hours or can it wait?
• Indications for chest drain insertion include
• Empyema confirmed following pleural aspiration.
• Confirmed diagnosis of a malignant pleural effusion with a Consultant decision to proceed with pleurodesis ( in this situation often a therapeutic tap is usually preferred with view to permanent tunnelled drain at a later date)
• Large pleural effusion causing significant distress and/or respiratory failure.
• Pneumothorax requiring drain according to the BTS guidelines.
• Haemothorax following traumatic injury to the lung.

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Pre-insertion considerations

• An information leaflet should be given to the patient ‘Having a chest drain inserted - Information for patients’’
• Bloods including FBC/clotting should be checked. PMH/DH/imaging should be reviewed.
• Written consent should be obtained before the procedure wherever possible in line with the Trust’s policy for consent to treatment and diagnostic procedures
• Where consent is not obtained due to the patient’s condition, this should be documented in the medical notes.
• Sterile gloves, gown, drapes should be used for insertion – these are available in the sterile packs provided.
• If possible a procedure room should be used for chest drain insertion.
• Seldinger drains (10-18F) would be the usual drain to be used to drain the pleural cavity other than for trauma or after cardio thoracic surgery.
• When inserting large bore drains, pre-medication with opioids/benzodiazepines should be considered if not contraindicated.

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Site and technique of drain insertion

• Insertion should usually take place in the “safe triangle” bordered by the anterior border of latissimus dorsi, the lateral border of pectoralis major, apex of axilla and the 5th intercostal space for a pneumothorax. For a pleural effusion as close the triangle of safety possible with ultrasound guidance.
• A chest drain should not be inserted if free air or fluid cannot be aspirated with a needle at the time of inserting local anaesthetic. - please seek senior advice
• A chest X-ray must be available before insertion except in the case of tension pneumothorax.
• The laterality and site should be marked.
• Ultrasound guidance is strongly recommended when inserting a drain for fluid.
• Ultrasound is not required when inserting a chest drain for a pneumothorax.
• At least level 1 competency is required to safely perform thoracic ultrasound independently.
• Local anaesthetic should be infiltrated prior to insertion of chest drain. You can use up to 3mg/kg of lidocaine (21mL of 1% lidocaine for a 70kg patient).
• Suture the drain.
• Blunt dissection should be used for large bore drains, but should not be used for Seldinger drains.
• Link to demonstration video below

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Management of drainage system

• Post procedure observations, CXR, chest drain chart and analgesia should be prescribed.
• Clear documentation of the procedure should appear in the notes.
• Drainage of a large pleural effusion should be controlled to prevent re-expansion pulmonary oedema - no more than 1.5 Litre (1 Litre in a smaller adult) should be drained in the first hour. Thereafter no more than 1 Litre an hour and when less than this can stay on free drainage.  Direct observation is recommended for the first 15mins (do not transfer during this time) to avoid excessive drainage of fluid.  After this every 15mins for first hour, hourly for 3 hours then every 4 hours.
• In cases of pneumothorax, clamping chest drains should be avoided.
• A bubbling chest drain should never be clamped.